Transcript

Now we love getting your letters or emails; it's a terrific reality check, among other things, and often points us to topics we haven't covered but should have. Like one Health Report listener who wrote in about her Frozen Shoulder. She'd like to remain anonymous but was happy to tell her tale to Brigitte Seega.

Woman: My life changed ten months ago when I found I was sitting on the bathroom floor weeping with pain within my right shoulder; I couldn't dry myself. So that started this long chain of going to doctors. Eventually I was diagnosed. First of all it was a rotator cuff problem, it would get better, it would settle down, and then quite soon I must say, I was diagnosed with what was called a Frozen Shoulder, technical term, Adhesive Capsulitis. So the first thing to do to relieve the pain which was absolutely unremitting and intense, I was given cortizone injections into the joint. There was one injection that they used ultrasound to direct it right into the capsule, and all these are quite painful procedures. But it didn't do any good for me.

And over time the condition deteriorated to the point where the arm became contracted into the body so that I no longer had an arm that fell loosely to the side. The arm lost almost all of its movement. I had no idea that it was going to become so painful and so limiting, and it affected every single thing: my daily life, my professional life, my social life. I became depressed, frustrated.

Brigitte Seega: So has it changed the way you do your work?

Woman: Yes. At home I had to develop strategies to do everything: to get up in the morning, to bath, to shower, to dress. I had to develop strategies to cook; really I actually went through a point where I was living on so little. I couldn't chop, I couldn't open the refrigerator door with my right arm.

Brigitte Seega: How has it influenced your ability to do your job?

Woman: I had to leave. My bread and butter money has been administration, which means computer work. My arm wouldn't come to the level of the table to write. Using the mouth was an impossibility.

Brigitte Seega: Are you receiving any other treatment at the moment?

Woman: Eventually when I found a good acupuncturist then that really gave me pain relief, there's no doubt. I don't think I could have survived without it.

Norman Swan: Well let's talk to someone who's made the shoulder joint his special interest: orthopaedic surgeon, David Sonnabend. David's a recognised authority in the field and is Professor of Orthopaedic Surgery at the University of New South Wales.

David Sonnabend: Well the shoulder joint's something like a ball and socket joint, but it's different to the hip; the hip's a true-born socket, where the ball is held by the socket. The shoulder is more a ball on a plate, so that it has an enormous range of movement; in fact it has a bigger range of movement than any other joint in the body.

Norman Swan: Why is it so easy to dislocate?

David Sonnabend: Because it's almost a flat surface. The socket of the ball and socket is almost flat, so the only things that hold it in are the capsule, which is really a very thin series of ligaments like an envelope between the ball and the socket, and then the bulk of the muscles that surround that.

Norman Swan: And is it a simple joint in terms of things going wrong? I mean you hear of Pat Rafter having a bad shoulder, and you hear of footballers having bad shoulders. Are there complex things that go wrong with the shoulder?

David Sonnabend: There are a lot of things that can go wrong, and it's interesting: 20 years ago there were only two things, you could break the neck of your humerus, you could dislocate your shoulder, or you're a malingerer. But now we find out that a lot of the malingerers have things wrong which the arthroscope has allowed us to pick up, and new imaging techniques and so on.

Norman Swan: The arthroscope being this tiny telescope, the flexible telescope that you stick in the joint to have a look around.

David Sonnabend: Yes, a little fibre optic telescope.

Norman Swan: So when we hear of the tennis player, the elite tennis player, having something wrong with their shoulder, is there a tennis shoulder, the same way there's a tennis elbow?

David Sonnabend: There is a tennis shoulder. There are two or three things they get, but they're all related. They're generally related to very minor instability, not the ball coming out of the socket, but just slipping a little bit. And with that little bit of slip putting a strain on either the rotator cuff, which is the main tendon of the shoulder, or on the labrum which is the rim that surrounds the socket.

Norman Swan: We should explain: a tendon is basically a strong piece of tissue which connects a muscle to bone and is the extension which pulls on the bone and allows the joint to straighten or flex.

David Sonnabend: That's right. When the muscle attaches to bone and has to have something between it and the bone, because the muscle will shred.

Norman Swan: So this rotator cuff comes from the shoulder muscles to the upper part of the arm?

David Sonnabend: That's right, and it's a common side of the abnormality. In fact as we get older, a lot of people have pathology in the rotator cuff they don't even now about. What we try to do is to provide the small and medium sized tears with a non-operative treatment regime, and the majority of them get better, at least as far as the pain is concerned. As we get older most of us can live with a little bit of weakness if we don't have pain. The commonest pain is night pain, the commonest reason for operating on a rotator cuff is people saying they can't sleep at night, they can't roll on their shoulder because it wakes them up.

Norman Swan: And when you operate you strengthen it?

David Sonnabend: You basically re-attach the torn tendon to bone, and sometimes you reinforce it with other tissues.

Norman Swan: And is that what a Frozen Shoulder is, a rotator cuff injury?

David Sonnabend: No it's not actually. A Frozen Shoulder relates to one layer closer to the middle of the joint. The Frozen Shoulder is something that happens inside the joint whereas the tendon is just on the outside of the joint. The capsule, or the membrane that holds the two parts together, lines the joint and just outside that are the tendons. Just inside that lining is a layer called synovium which is the common tissue that all major joints have, and that synovium seems to misbehave in people with Frozen Shoulders. So Frozen Shoulder means much as its name implies, that the ball and socket joint just doesn't move; the lining gets so tight and so scarred up.

Norman Swan: And what does somebody with a Frozen Shoulder complain of?

David Sonnabend: They have two complaints. Very early in the course of it, they don't actually notice the loss of movement. The first thing that happens is they have a very painful shoulder, and they come in saying, 'Out of the blue, I woke up on Monday morning; my shoulder was sore, and I haven't slept for the last three nights, and now it's terribly sore and I can't blow my nose or brush my hair.' And then after a few weeks they start to notice some loss of movement, but the initial complaint is usually pain.

Norman Swan: Who gets it?

David Sonnabend: You can get it at any age from about 30 or 35 up, but it is much commoner in women and it's much commoner around the mid-40s to 60s.

Norman Swan: And are there several roads that lead to Frozen Shoulder?

David Sonnabend: There are certainly different types of Frozen Shoulder. The one I've told you about is the so-called idiopathic or cause unknown, the commonest form. But there are other different pathways that lead to an equally frozen and stiff shoulder. Some people have major shoulder surgery and don't get going fast enough, they find the shoulder just doesn't get going at all; other people who have major injuries find that the injuries can precipitate a very stiff shoulder. Some people get it after the most unusual things: cardiothoracic surgery, especially people who go on bypass, for reasons we don't know, seem to have an increased risk of getting a Frozen Shoulder. The commonest non-idiopathic if you like, the commonest recognised risk is diabetes, and it can be either insulin-dependent or non-insulin-dependent.

Norman Swan: And for the commonest one, which is the one where you really don't know what the cause is, given you don't know the cause, how do you know how to treat it?

David Sonnabend: Well like so much in medicine, it's empirical. In other words we have a trial and error process, we find certain things work and certain things don't. And we can by implication say because it appears to be inflamed, medications that treat inflamation seem to help the Frozen Shoulder, without knowing why it's inflamed.

Norman Swan: This is why people give steroid injections for example?

David Sonnabend: That's correct, yes.

Norman Swan: Now this is something that goes away by itself, isn't it?

David Sonnabend: Over 95% of that idiopathic non-diabetic group will resolve completely, or almost completely with time. But the promise is it's a drawn-out process, so that I tell my patients there's good news and there's bad news. The good news is you're going to get better, and the bad news is it's going to take a long time.

Norman Swan: And what is a long time?

David Sonnabend: Usually 12 to 18 months is a reasonable natural history of the condition.

Norman Swan: So have there been any good scientific studies about treatments that reliably are known and safely known to reduce the length of the illness?

David Sonnabend: People have tried to get really good quality scientific evidence, and it probably doesn't really exist. But there are certainly well established methods that do shorten the course of the disease and people recognise as working. There are also some methods that are widely publicised which probably make little difference to the condition.

Norman Swan: So why don't you go through what works and what doesn't work?

David Sonnabend: It depends a little bit at what stage in the disease people treat it. In that initial, acute, inflamed, angry, painful stage the only things that seem to help are anti-inflammatory measures, whether it's oral anti-inflammatories, whether it's injected steroids, and they seem to suppress the pain and probably alter the end result. Once people get past that acute inflammation and start to lose range, then they're probably going to go through the whole process, it's only a matter of how severe it's going to be. The sort of modalities people have used in the past have included a lot of stretching, but of course if you've got a severely inflamed joint and you stretch it, the first thing you get is a terrible lot of pain, and there's a lot of evidence now that stretching at that early inflamed stage produces pain without gain.

As they go on, there have been some trials with seemingly good results, but no true controls, of injecting steroids and even just saline under pressure into the shoulder, and that's called hydraulic distension or dilatation, and what it does is, it seems to rupture the capsule that has been becoming tighter and tighter, and if you like it undoes the ropes that hold the shoulder together. But the reports of that has been very varied; like so many things some people seem to get great success, others can't copy or reproduce the results.

The things that seem to help best in terms of pain relief are injectible steroids. So people who have steroids injected into their shoulder joints seem to get really good pain relief, but possibly not much change in the actual duration of the condition. It's difficult to inject the shoulder; we all think we're good at playing darts, but if you take again a model or a cadaver and you try to inject it, even people who do it for a living, if they do it without some imaging, some ultrasound or x-ray to know they're there, very often miss the mark.

Norman Swan: So it's not something to be done in a GP surgery?

David Sonnabend: It can be done, but it would be preferable to be done by someone who could use either an ultrasound or a fluoroscope to be sure they're in the right place. The other risk of course, you inject steroids into a joint there's a small but real risk of infection, so it has to be done under the most sterile of conditions.

Recurrence occurs but is very, very rare. It's certainly not uncommon to get it on the other side, and of course while one Frozen Shoulder is a great disability, two Frozen Shoulders is a catastrophe, because people can't feed themselves, they can't dress themselves, they can't toilet themselves, and that suddenly becomes a major disability.

Norman Swan: Is there a surgical option at all?

David Sonnabend: There is a surgical option that people occasionally use. If people have the unusual diabetic type of Frozen Shoulder which often doesn't resolve, well those unfortunate people who get it on both sides and they really need some desperate relief quickly, can have the capsule in the joint released through the arthroscope. This is a good technique, it gives them a good range of movement back. They need to do a lot of exercise for a week or two after it. It works, but it has all the disadvantages of an operation: hospitalisation, cost, time off work and so on.

Norman Swan: David Sonnabend who's Professor of Orthopaedic Surgery at the University of New South Wales.

Guests

Dr. David Sonnabend

Professor of Orthopaedic Surgery,University of New South Wales,Kensington NSW